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President Donald Trump, followed by Health and Human Services Secretary Tom Price, far right, leaves the Capitol after rallying support for the Republican health care overhaul with GOP lawmakers two days before the House plans a climactic vote that poses ... more >

President Trump told House Republicans Tuesday they’ll lose their seats in the 2018 midterms, and could cost the GOP its majorities in Congress, if they don’t vote for his plan to repeal and replace Obamacare.

With a first floor vote looming Thursday, the White House said Mr. Trump wasn’t threatening retaliation, but rather predicting payback from voters angry at conservatives who squandered the one chance they’ll get to erase the massive 2010 health law and replace it with a more conservative solution.

“Honestly, a loss is not acceptable, folks,” the president told House Republicans.

Mr. Trump even called out the bill’s chief opponent, House Freedom Caucus Chairman Mark Meadows, in front of his colleagues, saying he would “come after” the North Carolinian if his group didn’t come around. The light-hearted nod to his bully pulpit and famous Twitter thumbs provoked laughter, yet it reflected a president who knows he cannot enact historic tax cuts and create a legacy unless he first delivers on health care.

Republicans tweaked the bill Monday night to try to entice holdouts, and House Speaker Paul D. Ryan said Republicans have finally struck the sweet spot of getting a conservative Obamacare repeal bill that can actually get through both chambers.

“This is our chance, and this is our moment,” Mr. Ryan said, calling the looming vote “a rendezvous with destiny” for Republicans.

Moderates have been reluctant to back the GOP repeal-and-replace legislation fearing it won’t work, while conservatives say the bill is ideologically damaged because it replaces the Obamacare entitlement with a new tax credit entitlement.

Mr. Meadows said GOP leaders still don’t have the votes, despite Mr. Trump’s entreaties, and must reopen negotiations on eliminating Obamacare’s coverage requirements and regulations on insurers to bring more of his members on board.

“Hopefully we’ll be able to do that,” Mr. Meadows, North Carolina Republican, said. “But if everyone’s entrenched at this particular point, it’s going to be a very difficult 48 hours.”

“I’m still a ‘no,” he added. “I’ve had no indication that any of my House Freedom Caucus colleagues have switched their votes.”

Mr. Ryan said conservatives are getting 85 percent of what they want in the bill, which he said should be considered a win in the legislative process.

Leaders say they can only do so much under arcane budget rules that allow them to avoid a Democratic filibuster in the Senate, so holdouts should take into account executive actions Mr. Trump will take and future bills congressional Republicans will write.

Asked on the way into the Capitol if he’d wrangled enough votes, Mr. Trump said, “I think so.”

“The higher the vote, the better,” Mr. Trump said inside the House meeting.

GOP leaders cannot afford to lose more than 21 GOP members, since every Democrat is expected to reject the bill that repeals most of Obamacare’s taxes and its mandate requiring Americans to hold insurance, replaces its generous subsidies with refundable, age-based tax credits and reins in and caps spending on Medicaid, the insurance program for the poor.

The Freedom Caucus boasts more than 30 members. Losing just half of them, alongside a cluster of moderates, could doom the bill.

As written, the Congressional Budget Office estimated the plan would save more than $300 billion over the next decade compared to Obamacare, but result in 24 million fewer people being insured 10 years from now. It would also significantly raise costs for Americans aged 50 to 64.

GOP leaders’ new changes would use at least $85 billion to enhance the tax credits for older Americans. The amendment leaves it to the Senate to actually formulate the enhanced credits.

Senate Democrats said the money amounted to a “slush fund” and that Republican plans would still hammer the neediest, including red-state voters who supported Mr. Trump by large margins.

“This isn’t a poke in the eye of Trump supporters, this is a two-by-four in their faces,” said Sen. Tim Kaine, Virginia Democrat. “They are against this bill.”

Among other changes GOP leaders made to their bill to entice holdouts were moving up the repeal of certain Obamacare taxes from 2018 to 2017 and allowing states to opt in on block granting federal funds for Medicaid and implementing a work requirement for the program.

Four House Republicans — Tom McClintock of California, Thomas MacArthur of New Jersey, Martha McSally of Arizona and Robert B. Aderholt of Alabama — said they were persuaded by provisions designed to help out older Americans.

Rep. John J. Faso, a New York Republican who’d wavered on the plan, said he was on board, in part because New York counties would no longer have to pay into the Medicaid system. Backers of the amendment cast it as local tax relief for their districts, though Democratic detractors said it merely shifted more costs onto the state.

Yet Rep. John Katko, New York Republican, said Tuesday he is still a “no.”

The Medicaid changes swayed key members to the Republican Study Committee, an influential bloc of conservatives, leaving the Freedom Caucus as the most visible impediment to passage.

One of Mr. Trump’s biggest allies said holdouts should heed his warning.

“It’s a binary choice now. It’s repeal or continue Obamacare,” Rep. Chris Collins, New York Republican, said. “And as the president said, if we don’t get this done, we’ll probably lose the House and the Senate next year.”

The House Rules Committee will meet early Wednesday to vet final changes to the GOP replacement and set the terms of debate for Thursday — the seventh anniversary of Obamacare’s passage.

Even if the bill clears the House, Senate Republicans are mulling their own changes, with floor action expected there next week.

While the U.S. Chamber of Commerce urged support for the bill Tuesday, Heritage Action, a conservative pressure group, said it is instructing Republicans to vote “no” or risk blowback during the campaign season.

The free market Club for Growth dialed up the pressure with a $500,000 ad buy that urges 10 centrist members to reject “Ryancare” because it doesn’t increase competition or drive down costs.

Sen. Tom Cotton, Arkansas Republican, released a statement Tuesday urging House leaders to slow down and get the policy right, echoing conservatives who say Mr. Trump’s pep talk didn’t win them over.